Naokazu Miyamoto

Comparison of Regional Brain Volume and Glucose Metabolism Between Patients with Mild Dementia with Lewy Bodies and Those with Mild Alzheimer's Disease

The aim of this study was to investigate regional differences between morphologic and functional changes in patients with mild dementia with Lewy bodies (DLB) compared with those with Alzheimers disease (AD). Methods: Twenty patients with very mild DLB (mean age, 74.5 y; mean Mini-Mental State Examination [MMSE] score, 24.0), 20 patients with very mild AD (mean age, 74.1 y; mean MMSE score, 24.0), and 20 age- and sex-matched healthy volunteers (normal controls [NC]) underwent both 18F-FDG PET and 3-dimensional spoiled gradient echo MRI. Fully automatic volumetry of the MRI data was used to obtain whole brain, hippocampal, occipital, and striatal volumes, which were compared with the results of a similar analysis of glucose metabolic data. Results: In DLB patients, volumetric data indicated a significant volume decrease in the striatum, whereas 18F-FDG PET showed significant glucose metabolic reductions in the temporal, parietal, and frontal areas—including in the occipital lobe—compared with those in the NC group. In contrast, in AD patients, both the hippocampal volume and glucose metabolism were significantly decreased, whereas the occipital volume and metabolism were preserved. Conclusion: Comparison of very mild DLB and AD revealed different morphologic and metabolic changes occurring in the medial temporal lobes and the occipital lobe, demonstrating characteristic pathophysiologic differences between these 2 diseases.

Fully automatic differential diagnosis system for dementia with Lewy bodies and Alzheimer’s disease using FDG-PET and 3D-SSP

PurposeTo evaluate a fully automatic computer-assisted diagnostic system for mild dementia with Lewy bodies (DLB), permitting distinction from mild Alzheimer’s disease (AD).MethodsUsing 18F-fluorodeoxyglucose and positron emission tomography (FDG-PET), glucose metabolic images were obtained from mild DLB and mild AD patients. Two groups consisting of 16 mild DLB patients and 21 mild AD patients were recruited for diagnostic evaluation between mild DLB and mild AD. The mean age ± SD of the mild DLB group and the mild AD group was 74.3 ± 4.9 and 71.7 ± 2.1 years, respectively, and the mean scores of the MMSE for the mild DLB and the mild AD group were 21.7 ± 1.9 and 23.1 ± 2.1, respectively. A receiver operating characteristic (ROC) analysis was performed to compare the diagnostic performance, in terms of discrimination between DLB and AD, of conventional axial FDG-PET images inspected visually by experts and beginners with that of our fully automatic diagnosis system using the statistical brain mapping method and Z scores obtained with the DLB template.ResultsThe diagnostic performance of the automatic system was comparable to that of visual inspection by experts. The area under the ROC curve for the automatic diagnosis system was 0.77. The mean area under the ROC curve for visual inspection by experts and beginners was 0.76 and 0.65, respectively.ConclusionThe fully automatic differential diagnosis system for distinction between mild DLB and AD showed a similar diagnostic accuracy to visual inspection by experts. It would be a useful diagnostic tool to distinguish mild DLB from mild AD in clinical practice.

Cerebral perfusion pattern of idiopathic normal pressure hydrocephalus studied by SPECT and statistical brain mapping.

Objectives: To investigate the specific pattern of cerebral blood flow (CBF) in subjects with idiopathic normal pressure hydrocephalus (iNPH) using voxel-based analysis.Methods:N-isopropyl-p-[123I]iodoamphetamine (IMP) single photon emission computed tomography (SPECT) images were performed in 30 iNPH patients, who met probable iNPH criteria, 30 Alzheimer disease (AD) patients and 15 normal control (NC) subjects. Inter-group comparisons between iNPH patients and NC subjects and between AD patients and NC subjects were performed using three-dimensional stereotactic surface projection (3D-SSP) analysis. Individual 3D-SSP images of the iNPH patients were assessed by visual inspection.Results: On the Z-score maps, areas of relative hypoperfusion were recognized around the corpus callosum in all 30 iNPH patients, as well as in the Sylvian fissure regions in 19 of 30 iNPH patients which included artifacts by dilated ventricles and the Sylvian fissures. Ten frontal dominant, eight parietotemporal dominant, and 12 diffuse hypoperfusion types were demonstrated. Inter-group comparison between iNPH and NC subjects showed relative hypoperfusion in the frontal and parietotemporal areas and severe hypoperfusion around the corpus callosum and Sylvian fissure regions, while parietotemporal and posterior cingulate CBF reduction was demonstrated between the AD and NC groups.Conclusion: Voxelbased analysis showed a characteristic pattern of regional CBF reduction with frontal dominant or diffuse cerebral hypoperfusion accompanying severe hypoperfusion around the corpus callosum and Sylvian fissures with artifacts.

Voxel-Based Analysis of Gray Matter and CSF Space in Idiopathic Normal Pressure Hydrocephalus

Aims: To investigate regional morphologic changes in idiopathic normal pressure hydrocephalus (INPH) based on diagnosis with INPH Guidelines using voxel-based morphometry. Method: Three-dimensional magnetic resonance imaging was performed in 34 INPH patients, who met probable INPH criteria, probable 34 Alzheimer disease patients, and 34 normal control subjects. Results: Statistical parametric mapping was used to conduct voxel-based morphometry analysis of the morphologic data and revealed enlarged ventricles and sylvian fissures and stenotic sulci of high convexity, especially in the precuneus in the INPH group, with decreased gray matter density in the insula, caudate and thalamus. Conclusion: In INPH, morphologic change occurs in the frontoparietal high convexity with ventricular dilatations, dilated sylvian fissures and tight sulci in the medial parietal lobes.

Therapeutic Effectiveness of Diagnostic Lymphangiography for Refractory Postoperative Chylothorax and Chylous Ascites: Correlation With Radiologic Findings and Preceding Medical Treatment

OBJECTIVE The purpose of this study was to assess the therapeutic effect of lymphangiography for refractory postoperative chylothorax and chylous ascites and analyze the relation between the clinical outcomes and radiologic findings or response to the preceding medical treatment. MATERIALS AND METHODS Between January 2004 and June 2012, 14 patients underwent lymphangiography. All patients had been unresponsive to at least two medical treatments for 3-62 days (median, 13.5 days) before lymphangiography. Leaks were classified as major, minor, and undetectable on the basis of radiologic findings including CT and conventional radiography after lymphangiography. The clinical outcomes were correlated with the radiologic findings or the changes of the daily chylous output after the preceding medical treatments. RESULTS The leaks were healed in nine of 14 patients (64.3%) by 3-29 days (median, 8 days) after lymphangiography. Healing was achieved for two of seven major leaks, and all of the minor leaks (n=4) and undetectable leaks (n=3) after lymphangiography. The remaining five major leaks were not healed after a median follow-up of 15 days. The daily output decreased more than half after medical treatment in seven of the 14 patients, and the leak was healed in six of these patients (85.7%) by 5-18 days (median, 10 days). CONCLUSION Lymphangiography might be useful for the treatment of refractory postoperative chylothorax and chylous ascites.

Computer-assisted diagnostic system for neurodegenerative dementia using brain SPECT and 3D-SSP

PurposeTo develop a computer-assisted automated diagnostic system to distinguish among Alzheimer disease (AD), dementia with Lewy bodies (DLB), and other degenerative disorders in patients with mild dementia.MethodsSingle photon emission computed tomography (SPECT) images with injection of N-Isopropyl-p-[123I]iodoamphetamine (IMP) were obtained from patients with mild degenerative dementia. First, datasets from 20 patients mild AD, 15 patients with dementia with DLB, and 17 healthy controls were used to develop an automated diagnosing system based on three-dimensional stereotactic surface projections (3D-SSP). AD- and DLB-specific regional templates were created using 3D-SSP, and critical Z scores in the templates were established. Datasets from 50 AD patients, 8 DLB patients, and 10 patients with non-AD/DLB type degenerative dementia (5 with frontotemporal dementia and 5 with progressive supranuclear palsy) were then used to test the diagnostic accuracy of the optimized automated system in comparison to the diagnostic interpretation of conventional IMP-SPECT images. These comparisons were performed to differentiate AD and DLB from non-AD/DLB and to distinguish AD from DLB. A receiver operating characteristic (ROC) analysis was performed.ResultsThe area under the ROC curve (Az) and the accuracy of the automated diagnosis system were 0.89 and 82%, respectively, for AD/DLB vs. non-AD/DLB patients, and 0.70 and 65%, respectively, for AD vs. DLB patients. The mean Az and the accuracy of the visual inspection were 0.84 and 77%, respectively, for AD/DLB vs. non-AD/DLB patients, and 0.70 and 65%, respectively, for AD vs. DLB patients. The mean Az and the accuracy of the combination of visual inspection and this system were 0.96 and 91%, respectively, for AD/DLB vs. non-AD/DLB patients, and 0.70 and 66%, respectively, for AD vs. DLB patients.ConclusionThe system developed in the present study achieved as good discrimination of AD, DLB, and other degenerative disorders in patients with mild dementia as the commonly performed visual inspection of conventional SPECT images. A combination of visual inspection and this system is helpful in the differential diagnosis of patients with mild dementia.

Automatic volumetric measurement of segmented brain structures on magnetic resonance imaging.

PurposeThe purpose of this study was to produce a fully automatic volumetric segmented brain image system (AVSIS) and to evaluate its utility for measuring hippocampal volumes and total intracranial volume (TIV).Materials and methodsWe developed a combination technique comprising an anatomical standardization technique to measure TIV, whole brain volume (WBV), and hippocampal volume obtained by magnetic resonance (MR) imaging. Altogether, 15 healthy volunteers and 15 patients with Alzheimers disease (AD) underwent three-dimensional spoiled gradient echo (3D-SPGR) imaging. Three measurements were performed by manual volumetry as the gold standard, a previous semiautomatic method, and our new method, AVSIS.ResultsWBV and hippocampal volume in the AD group were significantly smaller than those in the healthy volunteer group measured by the semiautomatic method, manual method, and AVSIS. Each volume measured by AVSIS or semiautomatic method correlated with that measured by the manual method. The correlation coefficients between TIVs, WBVs, or hippocampal volumes measured by AVSIS and the manual method were 0.910, 0.902, and 0.918, respectively; the correlation coefficients between TIVs, or WBVs, measured by the previous semiautomatic method and the manual method were 0.875, and 0.886, respectively.ConclusionWe developed a system for a fully automatic measurement of segmented brain structures and obtained good results.

Global cerebral hypoperfusion in a patient with transient global amnesia.

We report a 64-year-old male patient with pure transient global amnesia (TGA) who exhibited global cerebral hypoperfusion during an amnesia attack. Initial single photon emission computed tomography (SPECT) performed 3 hours after the onset of the amnesic attack revealed diffuse hypoperfusion in the cerebrum, whereas a second SPECT study, 1 month later, revealed improvement of cerebral blood flow. This case suggests that SPECT study is useful in revealing the pathophysiological mechanism of TGA and that TGA attacks are associated with global cerebral blood flow change.

Flow-preserved coil embolization using a side-holed indwelling catheter for common hepatic artery pseudoaneurysm: report of three cases

We report three cases of hepatic artery pseudoaneurysm, which were all treated successfully using a combination of coil embolization and a side-holed 5F indwelling catheter for maintaining minimal hepatic artery blood flow with exclusion of the pseudoaneurysm. The tip of an infusion catheter was placed in the right hepatic artery and a side hole was positioned at the celiac axis. Coil embolization was then performed from the proper to the common hepatic artery using detachable coils. Hemostasis was achieved in all patients, with a final angiogram showing the hepatic arteries through the indwelling catheter. One major hepatic infarction and one focal liver abscess caused by reflux cholangitis manifested on postoperative days (PODs) 11 and 87, respectively. All patients survived and the indwelling catheter was removed on POD 136–382 without complication.

Elderly case of Dieulafoy's lesion in the jejunum presenting with repeated hemorrhagic shocks

A 72-year-old man with hypertension was admitted to our hospital because of temporary stupor. On admission, neurological examination and brain magnetic resonance imaging showed no remarkable findings. Hemoglobin concentration of the blood was 14.4 g/dL. He developed shock following melena (day 1). Hematological examination after the shock revealed hemoglobin of 7.6 g/dL. Blood transfusion was performed. Initial gastrointestinal endoscopy and colonoscopy performed 4 h after the shock revealed blood in the colon, but did not reveal mucosal changes and the bleeding source. A second gastrointestinal endoscopy performed after a second shock revealed faint backward flow of the intestinal bleeding from the jejunum and did not show bleeding source in the esophagus, stomach and duodenum (day 2). Computed tomography (CT) and angiography performed on day 2 revealed the bleeding source (Fig. 1a– d). Although radiologists performed transcatheter arterial embolization (Fig. 1e), the patient developed a third shock following melena (day 4). A third gastrointestinal endoscopy showed a Dieulafoy’s lesion (DL) in the jejunum (Fig. 1f,g). We applied two clips and an endoscopic local injection of hypertonic saline– epinephrine solution. The hemostasis was successful. We could not perform gastrointestinal endoscopy after the treatment because of disappearance of melena and patient refusal. As in a similar previous report, we speculate that the DL in our case healed and disappeared. However, this could not be proven. Dieulafoy’s lesion is a vascular malformation and a rare but potentially life-threatening disease that is responsible for 7% of upper gastrointestinal hemorrhage. DL in the small intestine is extremely rare, and the diagnosis is difficult. In addition, elderly patients with DL can have several complications such as cardiovascular disease, chronic renal disease and dementia. Repeated hemorrhagic shocks can cause anemia and malnutrition, and worsen the general condition of elderly patients. Malnutrition among elderly patients leads to poor outcomes such as functional decline, frailty, the decline in quality of life and higher mortality. Nevertheless, DL located in the jejunum is beyond conventional gastrointestinal endoscopy. Angiography is useful for defining the lesion. Therefore, early detection of the bleeding source by repeated endoscopy, CT and angiography is necessary, and appropriate treatment is more important in elderly than young patients. Aging may be a risk factor for DL. The findings of DL in elderly patients suggest that atherosclerosis is associated with DL. DL also may be caused by an aneurysm in one of the vessels, perhaps in combination with atherosclerosis. Meanwhile, congenital or acquired vascular malformation might be an underlying cause in young patients. Although surgery had been performed in patients presenting with DL in the jejunum, endoscopic therapy is effective and safe in most cases. Endoscopic hemostasis is less invasive than surgery, especially for elderly patients. Although balloon-assisted enteroscopy recently has become practicable, this method was unavailable in our case. Transoral endoscopy accomplished by colonoscopy could be an alternative in emergency cases. This case highlights the unusual gastrointestinal hemorrhage that can induce repeated hemorrhagic shocks and malnutrition. The possibility of underlying causes in the small intestine should be kept in mind in patients with unusual gastrointestinal hemorrhage. Careful evaluation of the clinical and laboratory findings, and early treatment is important, especially in elderly patients. Geriatr Gerontol Int 2010; 10: 267–268